Trauma Care
● Importance of Trauma Care
● Principles of primary and secondary assessments.
● Establish management priorities.
● The leading cause of death in the first four decades of life.
● More than 5 million trauma-related deaths each year worldwide.
● Motor vehicle crashes cause over 1 million deaths per year.
● Injury accounts for 12% of the world’s burden of disease.
“When I can provide better care in the
field with limited resources than what
my children and I received at the
primary care facility there is
something wrong with the system,
and the system has to be changed.”James Styner, MD, FACS
1977
● ABCDE approach to evaluation and
treatment
● Treat greatest threat to life first
● Definitive diagnosis not immediately
important
● Time is of the essence
● Do no further harm
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: stop the bleeding!
Disability / neurological status
Expose / Environment / body temperature
Transfer
Reevaluation
Adjuncts
Adjuncts
Primary Survey
Resuscitation
Reevaluation
DetailedSecondary
Survey
Injury
Optimize patient status
● 24-year-old male involved in a motorcycle crash in to a truck
● Not wearing a helmet
● Arrives at hospital with the red crescent
● BP 80/40, P140, RR 33, and central cyanosis
● C-collar, Oxygen at 8L/min, Dressing to forehead & thigh soaked in blood
● Has a wrist splint & is on a spinal board
● Apply principles of primary and secondary surveys
● Identify management priorities
● Institute appropriate resuscitation and monitoring procedures
● Recognize the value of the patient history and biomechanics of injury
● Anticipate and manage pitfalls
● Cap● Gown● Gloves● Mask● Shoe covers● Goggles / face
shield
Primary survey and resuscitation of vital functions are done simultaneously using a team approach.
Definitive Care
Reevaluation
Adjuncts
Adjuncts
Primary Survey
Resuscitation
Reevaluation
DetailedSecondary
Survey
What is a quick, simple wayto assess a patient in 10
seconds?
What is a quick, simple way to assess a patient in 10 seconds?
● Identify yourself
● Ask the patient his or her name
● Ask the patient what happened
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion to permit cerebration
D Clear sensorium
Airway with c-spine protection
Breathing with adequate
oxygenation
Circulation with hemorrhage control
Disability
Exposure / Environment
The priorities are the same for all patients.
● Trauma in the elderly
● Pediatric trauma
● Trauma in pregnancy
Establish patent airway and protect c-spine
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate
Pitfalls
Airway
Basic Airway TechniquesChin-lift Maneuver
Basic Airway TechniquesJaw-thrust Maneuver
Advanced Airway TechniquesOrotracheal intubation
Assess and ensure adequate oxygenation and ventilation
● Respiratory rate
● Chest movement
● Air entry
● Oxygen saturation
Breathing
Breathing
Airway versus ventilation problem?
latrogenic pneumothoraxor
tension pneumothorax?
Pitfalls
BreathingThe Immediate life threatening injuries
● Laryngeotracheal injury / Airway obstruction
● Tension pneumothorax
● Open pneumothorax
● Flail chest and pulmonary contusion
● Massive hemothorax
● Cardiac tamponade
● Level of consciousness
● Skin color and temperature
● Pulse rate and character
Assess for organ perfusion
Circulation
● Control hemorrhage
● Restore volume
● Reassess patient
● Lethal triad
Elderly
Children
Athletes
Medications
Circulatory Management
Pitfalls
Disability
● Baseline neurologic evaluation
● Glasgow Coma Scale score
Disability
● Baseline neurologic evaluation
● Glasgow Coma Scale score
● Pupillary response
Disability
● Baseline neurologic evaluation
● Glasgow Coma Scale score
● Pupillary responseObserve for neurologic
deterioration
Caution
Prevent hypothermia
Exposure / Environment
Completely undress the patient
Missed injuries
Pitfalls
Caution
● Protect and secure airway
● Ventilate and oxygenate
● Stop the bleeding!
● Vigorous shock therapy
● Protect from hypothermia
PRIMARY SURVEY
PRIMARY SURVEY
Vital signsABGs
Pulseoximeterand CO2
Urinary / gastric cathetersunless contraindicated
Urinaryoutput
ECG
Diagnostic Tools
● FAST
● DPL
Consider Early Transfer
● Use time before transfer for resuscitation
● Do not delay transfer for diagnostic tests
The completehistory and
physicalexamination
After● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to normal
When do I start the secondary survey?
● History
● Physical exam: Head to toe
● Complete neurologic exam
● Special diagnostic tests
● Reevaluation
What are the components of the secondary survey?
History
Allergies
Medications
Past illnesses
Last meal
Events / Environment / Mechanism
Mechanisms of Injury
Unconsciousness
Periorbital edema
Occluded auditory canal
Head
Pitfalls
● External exam
● Scalp palpation
● Comprehensive eye and ear
exam
● Including visual acuity
● Bony crepitus
● Deformity
● Malocclusion
Maxillofacial
Potential airway obstruction
Cribriform plate fracture
Frequently missed
Pitfalls
Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction, hoarseness
Findings: Crepitus, hematoma, stridor, bruit
Neck (Soft Tissues)
Delayed symptoms and signs
Progressive airway obstruction
Occult injuries
Pitfalls
● Inspect
● Palpate
● Percuss
● Auscultate
● X-rays
Chest
The Potential life threatening injuries● Blunt cardiac injury
● Traumatic aortic disruption
● Blunt esophageal rupture
● Traumatic diaphragmatic injury
Chest
● Inspect / Auscultate
● Palpate / Percuss
● Reevaluate
● Special studies
Abdomen
Hollow viscous injury
Retroperitoneal injury
Pitfalls
● Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)
● Free air
● Diaphragmatic rupture
● Peritonitis
● Positive CT
Indications for Laparotomy – Blunt Trauma
● Hemodynamically abnormal
● Peritonitis
● Evisceration
● Positive DPL, FAST, or CT
Indications for Laparotomy – Penetrating Trauma
Perineum Contusions, hematomas, lacerations, urethral blood
Rectum Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood
VaginaBlood, lacerations
Urethral injury
Pregnancy
Pitfalls
● Pain on palpation● Leg length unequal● Instability● X-rays as needed
Pelvis
Excessive pelvic manipulation
Underestimating pelvic blood loss
Pitfalls
● Contusion, deformity
● Pain● Perfusion● Peripheral
neurovascular status
● X-rays as needed
Extremities
Potential blood lossMissed fractures
Soft tissue or ligamentous injuryCompartment syndrome (especially
with altered sensorium / hypotension)
Musculoskeletal
Pitfalls
● GCS ● Pupil size and reaction● Lateralizing signs● Frequent reevaluation● Prevent secondary
brain injury
Earlyneurosurgical
consult
Neurologic: Brain
Altered sensorium
Inability to cooperate with clinical exam
● Whole spine● Tenderness and swelling● Complete motor and sensory exams● Reflexes● Imaging studies
Neurologic: Spinal Assessment
Pitfalls
Early neurosurgical /
orthopedic consult
Neurologic: Spine and CordConduct an in-depth evaluation of the patient’s spine and spinal cord
Special Diagnostic Tests as Indicated
Patient deterioration
Delay of transfer
Deterioration during transfer
Poor communication
Pitfalls
● High index of suspicion
● Frequent reevaluation and monitoring
How do I minimize missed injuries?
● Relief of pain / anxiety as appropriate
● Administer intravenously
● Careful monitoring is essential
Which patients do I transfer to a higher level of care?
Which patients do I transfer to a higher level of care?
Those whose injuries exceed institutional capabilities:
● Multisystem or complex injuries
● Patients with comorbidity or age extremes
When should the transfer occur?
Which patients do I transfer to a higher level of care?
As soon as possible after stabilization:
● Airway and ventilatory control
● Hemorrhage control
Transfer agreements
Local resources
Trauma center
Specialtyfacility
Local facility
● Rapid accurate assessment
● Resuscitate and stabilize by priority
● Determine needs and capabilities
● Arrange for transfer to definitive
care
● Ensure optimum care
● ABCDE approach to trauma care
● Do no further harm
● Treat the greatest threat to life first
● One safe way
● A common language
Definitive Care
Reevaluation
Adjuncts
Adjuncts
Primary Survey
Resuscitation
Reevaluation
DetailedSecondary
Survey
Questions
